<div id="content">
    <div class="paypall_wrapper">
        <div class="paypall_header">
            <h1>Review shipping address</h1>
        </div>
        <div class="paypall_main">
            <form class="autoform" id="payment" method="post">
                <div class="paypall_left">
                   <label for="payment-customerCustomer"><span class="paypall_field_name">Full name</span></label>
                   <label for="payment-customerEmail"><span class="paypall_field_name">Email</span></label>
                   <label for="payment-customerAddress"><span class="paypall_field_name">Address</span></label>
                   <label for="payment-customerCity"><span class="paypall_field_name">City</span></label>
                   <label for="payment-customerState"><span class="paypall_field_name">State</span></label>
                   <label for="payment-customerZip"><span class="paypall_field_name">ZIP-code</span></label>
                   <label for="payment-customerPhone"><span class="paypall_field_name">Phone</span></label>
                   <label for="payment-customerComment"><span class="paypall_field_name">Comment</span></label>
               </div>
                <div class="paypall_right">

                    <div class="paypall_textbox">
                        <input class="paypall_input_text" type="text" id="payment-customerCustomer" value="<?=isset($form->elements['customerCustomer']->value)?$form->elements['customerCustomer']->value:''?>" name="payment[customerCustomer]"/>
                        <?=isset($form->elements['customerCustomer']->errors[0])? "<span class='form_error'>".$form->elements['customerCustomer']->errors['0'] ."</span>" :''?>
                    </div>

                    <div class="paypall_textbox">
                        <input class="paypall_input_text" type="text" id="payment-customerEmail" value="<?=isset($form->elements['customerEmail']->value)?$form->elements['customerEmail']->value:''?>" name="payment[customerEmail]"/>
                        <?=isset($form->elements['customerEmail']->errors[0])? "<span class='form_error'>".$form->elements['customerEmail']->errors['0'] ."</span>" :''?>
                    </div>

                    <div class="paypall_textbox">
                        <input class="paypall_input_text" type="text" id="payment-customerAddress" value="<?=isset($form->elements['customerAddress']->value)?$form->elements['customerAddress']->value:''?>" name="payment[customerAddress]"/>
                        <?=isset($form->elements['customerAddress']->errors[0])? "<span class='form_error'>".$form->elements['customerAddress']->errors['0'] ."</span>" :''?>
                    </div>

                    <div class="paypall_textbox">
                        <input class="paypall_input_text" type="text" id="payment-customerCity" value="<?=isset($form->elements['customerCity']->value)?$form->elements['customerCity']->value:''?>" name="payment[customerCity]"/>
                        <?=isset($form->elements['customerCity']->errors[0])? "<span class='form_error'>".$form->elements['customerCity']->errors['0'] ."</span>" :''?>
                    </div>



                    <div class="paypall_textbox">
                        <select class="contact_input_text" id="payment-customerState" name="payment[customerState]">
                            <option selected="selected" value=""></option>
                            <option value="AL">Alabama</option>
                            <option value="AK">Alaska</option>
                            <option value="AS">American Samoa</option>
                            <option value="AZ">Arizona</option>
                            <option value="AR">Arkansas</option>
                            <option value="CA">California</option>
                            <option value="CO">Colorado</option>
                            <option value="CT">Connecticut</option>
                            <option value="DE">Delaware</option>
                            <option value="DC">District of Columbia</option>
                            <option value="FM">Federated States of Micronesia</option>
                            <option value="FL">Florida</option>
                            <option value="GA">Georgia</option>
                            <option value="GU">Guam</option>
                            <option value="HI">Hawaii</option>
                            <option value="ID">Idaho</option>
                            <option value="IL">Illinois</option>
                            <option value="IN">Indiana</option>
                            <option value="IA">Iowa</option>
                            <option value="KS">Kansas</option>
                            <option value="KY">Kentucky</option>
                            <option value="LA">Louisiana</option>
                            <option value="ME">Maine</option>
                            <option value="MH">Marshall Islands</option>
                            <option value="MD">Maryland</option>
                            <option value="MA">Massachusetts</option>
                            <option value="MI">Michigan</option>
                            <option value="MN">Minnesota</option>
                            <option value="MS">Mississippi</option>
                            <option value="MO">Missouri</option>
                            <option value="MT">Montana</option>
                            <option value="NE">Nebraska</option>
                            <option value="NV">Nevada</option>
                            <option value="NH">New Hampshire</option>
                            <option value="NJ">New Jersey</option>
                            <option value="NM">New Mexico</option>
                            <option value="NY">New York</option>
                            <option value="NC">North Carolina</option>
                            <option value="ND">North Dakota</option>
                            <option value="MP">Northern Mariana Islands</option>
                            <option value="OH">Ohio</option>
                            <option value="OK">Oklahoma</option>
                            <option value="OR">Oregon</option>
                            <option value="PW">Palau</option>
                            <option value="PA">Pennsylvania</option>
                            <option value="PR">Puerto Rico</option>
                            <option value="RI">Rhode Island</option>
                            <option value="SC">South Carolina</option>
                            <option value="SD">South Dakota</option>
                            <option value="TN">Tennessee</option>
                            <option value="TX">Texas</option>
                            <option value="UT">Utah</option>
                            <option value="VT">Vermont</option>
                            <option value="VI">Virgin Islands</option>
                            <option value="VA">Virginia</option>
                            <option value="WA">Washington</option>
                            <option value="WV">West Virginia</option>
                            <option value="WI">Wisconsin</option>
                            <option value="WY">Wyoming</option>
                        </select>
                        <?=isset($form->elements['customerState']->errors[0])? "<span class='form_error'>".$form->elements['customerState']->errors['0'] ."</span>" :''?>
                    </div>

                    <div class="paypall_textbox">
                        <input class="paypall_input_text" type="text" id="payment-customerZip" value="<?=isset($form->elements['customerZip']->value)?$form->elements['customerZip']->value:''?>" name="payment[customerZip]"/>
                        <?=isset($form->elements['customerZip']->errors[0])? "<span class='form_error'>".$form->elements['customerZip']->errors['0'] ."</span>" :''?>
                    </div>

                    <div class="paypall_textbox">
                        <input class="paypall_input_text" type="text" id="payment-customerPhone" value="<?=isset($form->elements['customerPhone']->value)?$form->elements['customerPhone']->value:''?>" name="payment[customerPhone]"/>
                        <?=isset($form->elements['customerPhone']->errors[0])? "<span class='form_error'>".$form->elements['customerPhone']->errors['0'] ."</span>" :''?>
                   </div>

                   <div class="paypall_textarea">
                        <textarea  rows="10" cols="25" id="payment-customerComment" name="payment[customerComment]"><?=isset($form->elements['customerComment']->value)?$form->elements['customerComment']->value:''?></textarea>
                        <?=isset($form->elements['customerComment']->errors[0])? "<span class='form_error'>".$form->elements['customerComment']->errors['0'] ."</span>" :''?>
                   </div>

                </div>

                <div style="clear: both"></div>
                <div class="paypall_bottom">
                    <input class="submit" id="payment-submit" type="submit" name="payment[submit]" value="Pay now"/>
                    <a href="/commerce/checkout/">&larr;back to order review</a>
                </div>
            </form>
        </div>
    </div>
</div>
